Form U-140 - Application For Drug-Free Safety Program
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1Application for
Drug-Free Safety Program
Instructions
You may submit the completed form in one of three ways listed below.
1.
Apply online at
2.
Fax it to 614-621-1405.
3.
Mail to:
Attention: Employer Programs
Ohio Bureau of Workers’ Compensation
30 W. Spring St., 22nd Floor
Columbus, OH 43215-2256
Employer information
Federal Tax ID number
BWC policy number
Name of employer and DBA
Address
City
State
ZIP code
Telephone number
Fax number
Email address
Contact information
Contact name
Contact title
Contact email
Contact telephone number
Contact fax number
Note
While participating in the Drug-Free Safety Program, you should verify other BWC programs that are compatible
with it. You may participate in more than one BWC program. However, only certain programs may be combined in
the bonus calculation. Please reference the compatibility chart found in Ohio Administrative Code 4123-17-74.
Check the program/level for which you are requesting approval.
Advanced level
n Basic level
n Comparable program
Number of employees
n
Do you want BWC to place you in the State of Ohio construction contractor/subcontractor database, thereby making you eligible
Yes
n
to bid and/or work on state construction projects?
(Employer wants to be listed as “approved” in state construction database.)
No
n
I hereby certify my organization is applying to implement a DFSP pursuant to Rule 4123-17-58 of the Ohio Administrative Code.
I also certify my organization is willing to meet, at minimum, the requirements associated with the level of program for which
I have applied (Advanced, Basic or Comparable). This includes timely submission of a fully completed annual report, which
BWC must receive by the deadline date or be post marked by that date as specified by rule. When failing to fully implement the
DFSP or meet the specified requirements, I agree to promptly repay to the BWC any DFSP bonus received. Also, I certify this
information is accurate and, if not, may subject the employer applicant and myself to civil and criminal penalties.
Name of designated employer representative certifying intent to comply and willingness to pay back discounts for non-compliance.
Owner/partner; officer name
Title
Signature
Date signed
X
BWC-7646 (Rev. Oct. 2, 2014)
U-140
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